From pages 385-6 on the examination of the abdomen in Textbook of Physical Diagnosis: History and Examination by Mark H. Swartz, M.D.:

"Ubtra-abdominal inflammation may involve the psoas muscle. A special test performed when there is suspicion of intra-abdominal inflammation is the iliopsoas test. The patient is asked to lie on the unaffected side and extend the other leg at the hip against the resistance of the examiner's hand. A positive psoas sign is abdominal pain with this maneuver. Irritation of the right psoas muscle by an acutely inflammed appendix produces a right psoas sign.

Another useful test for inflammation is the obturator test. While the patient is lying on the back, the examiner flexes the patient's thigh at the hip, with the patient's knees bent, and rotates the leg internally and externally at the hip. If there is an inflammatory process adjacent to the obturaor muscle, pain is elicited."

which examiner performs these on the patient?it seems unfair to make the patient endure the pain more often than onceand there is mention of the digital rectal exam - is this done by the physician or the nurse - again this would seem unkind to the patient to make the patient endure double the painful tests?thanks

Interesting that,we were always taught to press "Mcburnies Point" which is sort of a central point between the right hip bone and the pubic bone .A positive sign was guarding when you remove the pressure.

Appendicitis is not always easily dx. That's why the physician/APN have these examination guidelines. But, the psoas, obturator signs, if absent, should never r/o appendicitis.

One must consider differential dx as well. Such as (not all inclusive):

diverticulitis

endometriosis

even acute cholecystitis

Classic s/s do not always readily avail themselves in those with appendicitis. One classic sign that I observe is vomiting after the onset of pain. If vomiting occurs before pain starts, one should reevaluate the situation for it probably is not appendicitis.

As for the rectal exam, in those cases where the provider failed to accurately dx appendicitis and the patient went on to perforate, this has been one issue cited in malpractice claims: failure to perform digital rectal exam

Interesting that,we were always taught to press "Mcburnies Point" which is sort of a central point between the right hip bone and the pubic bone .A positive sign was guarding when you remove the pressure.

this is another question - in Jarvis: "choose a site away from the painful area" - this is how Blumberg's sign for rebound tenderness is done - on the left side of the abdomen (with photographs to demonstrate pressure on the left side of the abdomen, not the right side). The pain will be at McBurney's point, on the right side, but don't press there.

Then there's Rovsing's sign - press on the opposite side of the abdomen

And in Jarvis, we are taught to do rectal exams, so even if this is an invasive procedure - we have been taught this procedure. And I have also read that when rectal exam is not done, even though this procedure has some controversy, failure to do the rectal exam has resulted in successful malpractice claims (explained in this article: http://www.emedicine.com/emerg/topic41.htm